Immunologic evaluation in infective endocarditis.

OBJECTIVE: To analyze the immune response in peripheral blood of patients with infective endocarditis. METHODS: We studied 10 patients with infective endocarditis, age range from 20 to 50 years-old, males and females, and 20 healthy subjects in the same age range. The diagnosis of the disease was based on the clinical picture, echocardiogram, and hemoculture based upon samples drawn and tested before the treatment started. The were no history of atopy or malnutrition, no autoimmune disease, and they were not using any immunosuppressant or antibiotic medication. RESULTS: The patients with endocarditis had significantly higher T and B lymphocyte, CD4+ and CD8+ cell counts, IgM and IgG serum levels, and C4 component of the complement than the control group; no significant difference concerning serum IgA and neutrophil oxidative metabolism; a significant decrease in C3, chemotaxis, and monocyte phagocytosis;cryoglobulins were detected in 66.6% of patients and they were formed by IgG, IgM, IgA, C3, and C4. CONCLUSION: The patients with infective endocarditis were immunocompetent in most sectors of immune response and, at a certain moment, an autoimmune component may be present.

[Iatrogeny in cardiology]. / Iatrogenia em cardiologia.

The word iatrogeny derives from the Greek and concerns any disorder caused to the patient by inaproppriate medical practice. Unfortunately, the rise of an iatrogenic disease is related to the daily handline of cardiac disease. There are two types of iatrogeny: that caused by a medical action and omission iatrogeny, caused by the lack of a medical action. Iatrogeny occurs in all steps of medical practice starting with the patient-doctor relationship including diagnosis treatment and finally prevention of diseases. This article makes a brief commentary about iatrogenic heart disease and mentions some examples of it.

Pseudo-myocardial infarction during an episode of herpes zoster.

The patient arrived at the emergency unit with a history of acute myocardial infarction, for which she was treated. Without improvement in the pain, the patient developed heart failure and underwent a hemodynamic study, which showed normal coronary arteries and extensive ventricular impairment. During evolution, the clinical findings improved and herpes zoster appeared on the right shoulder. In a few months the clinical findings subsided, and the findings of the electrocardiogram, chest X-ray, and ventricular function were normal. The patient is currently asymptomatic.

Terapia e evoluçäo do candidato a receptor do transplante cardíaco / Therapy and evolution of the candidate to heart transplantation

As doenças mais comuns que acometem o candidato a transplante cardíaco säo as cardiomiopatias, a doença coronária e, menos frequentemente, a doença cardíaca congênita e a rejeiçäo do enxerto. No Estudo de Framingham, foi demonstrado que a sobrevivência do paciente com insuficiência cardíaca é menor que 50 por cento em cinco anos após o início dos sintomas. Em outros estudos, na insuficiência cardíaca com sintomas avançados a sobrevivência chega a ser de 40 por cento - 60 por cento após um ano. O coecimento da fisiopatologia da insuficiência cardíaca, principalmente dos mecanismos neuro-hormonais e dos fatores prognósticos, tem proporcionado abordagens terapêuticas mais adequadas para melhorar os sintomas, a qualidade de vida e a sobrevivência dese grupo de pacientes. Apesar da melhora na sobrevida, o prognóstico ainda continua pobre; por isso, novas abordagens devem ser encontradas. A abordagem terapêutica de que dispomos no momento serve para retardar a evoluçäo da doença e controlar o paciente oo ponte para o transplante cardíaco.

[Transesophageal echocardiography in atrial fibrillation as diagnosis of embolic source and its relation with embolic accidents]. / Ecocardiografia transesofágica na fibrilação atrial como diagnóstico de fonte embolígena e sua relação com acidentes embólicos.

PURPOSE: To determine, by means of transesophageal echocardiography (TEE), the risk factors for intracavitary thrombosis or prethrombotic state and for embolic accidents in patients with atrial fibrillation. METHODS: We studied 49 patients with chronic atrial fibrillation, submitted to clinical examination, EKG, chest X-ray, and TEE. RESULTS: Thirty percent of patients had valvopathies, 29% myocardiopathies, intracavitary thrombus or prethrombotic state were found in 37%, 40% of them had embolic accidents. We did not find statistical significance between myocardiopathies and valvulopathies. The left atrial diameter did not preview embolic accidents. We have observed 6 patients without structural cardiopathies, three of them presented embolic events, and one prethrombotic state. CONCLUSION: Embolic phenomena are inherent to atrial fibrillation and independent of structural cardiopathies, with indication to prophylactic use of oral anticoagulants.

[Thrombolytic therapy in thrombosis of prosthesis]. / Terapêutica trombolítica nas tromboses de próteses mecânicas.

PURPOSE: To relate our experience with thrombolytic therapy in 8 patients with cardiac metal prosthesis complicated with thrombosis. METHODS: Eight patients with clinical and echocardiographic diagnosis of cardiac valvar prosthesis thrombosis were treated. RESULTS: The treatment efficacy was evaluated by clinical and echocardiographic improvement. The authors recognized improvement in all 8 patients. One case of hemorrhage was observed (coxo-femoral articulation). Late death were observed twice: 24 months after, sudden death and 30 months later by hemorrhagic stroke. CONCLUSION: The results indicated that thrombolytic therapy is best way to treat patients with cardiac valve thrombosis, instead of surgical treatment.

[Infectious endocarditis. Analysis of 20 death cases in Santa Casa de São Paulo]. / Endocardite infecciosa. Análise de 20 casos de óbito na Santa Casa de São Paulo.

PURPOSE: To analyze the clinical, laboratory and pathological aspects of 20 cases of infectious endocarditis (IE) who died. The authors compared patients with diagnosis before death of IE and those with diagnosis was made after autopsy. METHODS: Twenty patients who died with IE between April 1982 and November 1991 were studied. We looked for the clinical aspects (fever, cardiac murmurs, anemia, splenomegaly, embolic events and skin manifestation), laboratory aspects (hemocultures), echocardiographic and anatomopathologic features (valvar vegetations events and embolic accidents founded at autopsy). The sample was divided in two sub-groups: A--with clinical diagnosis of IE before and B--without diagnosis before death. RESULTS: Group A--9 patients aged 8-58 years, 3 men, all them with cardiac murmurs, fever and anemia, 5 with splenomegaly. Hemocultures were done in 7 patients and positive in 1. Echocardiogram with valvar vegetation were found in 4 out of 5 patients (80% positive). At autopsy mitral valve vegetation were present in 7, aortic 3, tricuspid 3. One patient showed the exposure of three valves and two of 2 valves. Embolic events were found in 4. Group B--11 patients most of them older then 50 years (54.5%) (p < 0.05) 5 men, all them presented fever and anemia. Cardiac murmurs in 6 (54%) and none with splenomegaly. In one case hemoculture and echocardiogram, were done and were negative. Anatopathologic study showed compromise of mitral valve in 5, aortic 4, tricuspid 2, pulmonary 1. Two patients had 2 valves compromised. In one case a mural vegetation (right atrium) was found. Embolic events were present in 2 cases. CONCLUSION: In group B a significant number of patients (p < 0.05) were older than 50 years and presented his symptoms as an acute illness. We concluded that older patients with compromised general state and fever with or without embolic events IE must be remember.

[Bacteremia induced by labor. Is prophylaxis for infective endocarditis necessary?]. / Bacteremia induzida pelo trabalho de parto. Cabe a profilaxia da endocardite infecciosa?

PURPOSE: To characterize the occurrence of bacteremia during delivery and to verify the necessity of prophylaxis against infective endocarditis. METHODS: The authors collected hemoculture of 100 women, 15,30 and 45 minutes after delivery. The data were collected from May 1992 until May 1993. The positive hemocultures were followed by antibiogram. RESULTS: Seven hemocultures were positive: six for Staphylococcus, one for Candida sp, Penicilium sp, Clandosporum sp and Aspergillus sp that were found in association. Four patients had prematures amniorrhexis, longer than 6 hours before delivery (p < 0.05). Six patients had labor longer than 6 hours after admission (p < 0.05). The authors did not observe differences related to vaginal delivery with or without forceps or cesarean section. The samples were all sensible to cefalotin at the antibiogram. CONCLUSION: Labor and delivery is a high risk procedure for bacteremia and so for ineffective endocarditis in susceptible patients. The statistical analysis recognize as risk factors labor longer than 6 hours inside the hospital and premature amniorrhexis. We propose the use of intravenous cefalotin 1g 60 minutes before expulsion and repeated 6 and 12 hours later.

[The Q wave in the electrocardiogram: necrosis or an electrically inactive area? Myocardial pseudoinfarct]. / Onda Q do eletrocardiograma: necrose ou zona eletricamente inativa? O pseudo-infarto do miocárdio.

Six patients with Q-wave myocardial infarction in the ECG, two with coronary disease, two with metabolic alterations, one with acute myocarditis and another with ischemic stroke had an improvement of ECG tracings with disappearance of the Q wave. All had normal plasmatic levels of CPK and CKMB. It is believed that metabolic transitory disturbance of the myocardium increases the rest transmembrane potential turning the cell nonresponsive to electrical stimulus and without mechanical activity (inactive electrical zone, not a necrosis zone, which is an anatomo-pathological diagnosis).

[Mitral valve replacement with porcine bioprosthesis in children. Evaluation of 29 patients during 12 years]. / Substituição valvar mitral por bioprótese porcina em crianças. Avaliação de 29 pacientes durante 12 anos.

PURPOSE: To analyze the clinical result of the mitral valve substitution for the porcine bioprostheses, the incidence of dysfunction caused by calcification and its importance related to the durability of bioprostheses and also the patients' survival. METHODS: Twenty-nine children of about seven to sixteen years old were operated on from November 1977 to August 1982 and all of them received porcine bioprostheses of low profile. RESULTS: There were three (10.34%) hospital deaths and nine other late mortalities. The follow-up period varied from 4 to 128 months with average of 58.17 months and with the loss of nine patients. An actuarial survival rate of 46.08% has been observed at 11 years after surgery. Calcification of 21 bioprostheses occurred in 14 out of 17 follow-up patients; 47.6% of them happened until the third year of pos-operative and 85.7% until the fifth year. Eleven patients were reoperated on with 9.09% of hospital mortality. There were no cases of thromboembolism. CONCLUSION: Porcine bioprostheses works well with an evident clinical improvement of patients, with no thromboembolic accidents. However, its durability has been affected by the high incidence of calcification, which is responsible for an increase in late morbidity and mortality. Mitral valve disease treatment in children must be conservative, in an attempt to solve the problem with the different available plastic technics and leave the valve substitution to be a last option. In that case, the preference is given to the homologous bioprostheses.

[Analysis of fever in 58 cases of infective endocarditis]. / Análise da febre em 58 casos de endocardite infecciosa.

PURPOSE: To evaluate if fever is an objective criterion in the assessment of response to antibiotic therapy and in the prognosis of patients undergoing treatment for infective endocarditis (IE). METHODS: Fifty-eight cases of IE, occurring from January 1980 to December 1989 have been analysed retrospectively in this study. Emphasis was given to the clinical history and body temperature changes during the first five weeks of treatment. Patients were divided in three groups according to the number of febrile peaks per week. Temperature was assessed weekly from each patient's highest peak weighed average. RESULTS: At the first exam, 52 patients (86.2%) presented fever. All patients had at least one episode of fever during their hospitalization. There seemed to be a relation between the number of febrile peaks during a one week period and the mean body temperature, so that these patients who presented four or more peaks in a week had a higher mean body temperature than those with two or less febrile peaks during the week. After the second week of treatment, patients with two or less febrile peaks had a 93.1% survival and average of 35.5 days of hospitalization, whereas those with three or more febrile peaks had 63.6% survival and an average of 47.5 days of hospitalization. CONCLUSION: The results of this study show that the intensity of fever is linked to the number of febrile peaks per week, regardless to treatment duration. Should there be three or more febrile peaks weekly after the second week of treatment, therapeutic strategy should be reviewed, considering even surgical treatment. In many cases, the persistence of fever represented the clinical expression of complications which determined a higher mortality rate and a longer hospitalization.

[Cor triatriatum]. / Cor triatriatum.

A 16-year-old patient was evaluated for congestive heart failure and pulmonary hypertension, suggesting mitral valve stenosis. A left atrial membrane with a 4 mm orifice was seen in echocardiography and angiography, and a diagnosis of cor triatriatum was made. The membrane was successfully removed by surgery.

[Infective endocarditis. Study of 83 cases at the Hospital da Santa Casa de São Paulo]. / Endocardite infecciosa. Estudo de 83 casos no Hospital da Santa Casa de São Paulo.

PURPOSE: To analyse clinical aspects, diagnosis and treatment of infective endocarditis (IE), in order to guide medical procedures and indicate the surgical treatment. PATIENTS AND METHODS: 83 patients were submitted to clinical treatment of IE between January 1980 and December 1987; clinical aspects, laboratory and pathologic-anatomy findings, the site of infection and the entrance of micro-organism were studied. RESULTS: 37 (44.6%) patients were males. Fever was present in 75 (90.4%) cases, cardiac murmur in 76 (91.5%), splenomegaly in 28 (33.7%) and heart failure (III and IV) in 32 (39.8%) patients. Blood culture was positive in 55.5%; staphylococcus 50% of blood cultures; anemia was present in 66 cases (79.5%) and high serum mucoprotein in 58 (92%); echocardiography was 85.7% positive. The mortality was 39.76%; congestive heart failure was the main cause of death; 78.1% of these ones occurred in the first 15 days of antibiotic-therapy. The mitral valve was the one most impaired and the most frequent entrance of micro-organisms in oropharynx. CONCLUSION: Congestive heart failure, sepsis and systemic embolisms were the main complications that led the patient to death in course of IE, usually before 15 days of antibiotic-therapy. In these cases, we may hypothesize that prompt surgical treatment could have diminished the mortality of IE.

[Acute myocardial infarction in patients over 70 years of age. Study of 51 cases]. / Infarto agudo do miocárdio em pacientes acima de 70 anos. Estudo de 51 casos.

PURPOSE: To describe the clinic evolution during admission of a group of patients over age 70, who experienced acute myocardial infarction (AMI). PATIENTS AND METHODS: Fifty-one patients, over age 70, with confirmed diagnosis of AMI, were studied. Thirty-six (70.6%) males and 15 (29.4%) females. RESULTS: Near half (49.1%) were admitted before four hours of beginning of pain. The complications were divided into mechanical, electrical, persistent ischemia and others, not related with coronary heart disease. In the coronary care unit (CCU), 84.3% of patients complicated, and 50.0% at the ward. AMI of the anterior wall complicated more frequently with tachiarrhythmia, and inferior wall with atrioventricular block. There were not statistical difference in the incidence of mechanical complications, according to the affected wall. There was statistical significance (p less than 0.05) comparing mortality and the time elapsed between beginning of pain and hospital admission, but not comparing mortality and the wall involved. The patients with congestive heart failure and cardiogenic shock died in 93.3%. Mortality at the CCU was mostly related to complications of AMI, but mortality at ward to other complications not directly related with coronary heart disease. CONCLUSION: Myocardial infarction over age 70 implies high mortality and morbidity, with significantly, better prognosis with earlier arrival of the patient to the hospital.

[The porcine valve prosthesis and pregnancy]. / Prótese valvar porcina e gravidez.

Anticoagulation is the chief problem during pregnancy of women with mechanical prosthetic valves. Many studies have investigated a nonthrombogenic valve. Since 1978 we have used a biological porcine prosthetic valves in 16 pregnancies, 11 patients with regular clinical electrocardiographic, echocardiographic and chest roentgenographic follow-up. The patients' ages were 19 to 32 years during pregnancy. Nine had mitral, one aortic and one mitro-aortic prosthesis. Two patients dropped out during the study so we completed it with 14 pregnancies. Six patients coursed with grade I heart failure (HYHA), five grade II and three grade IV. All of them were treated clinically. Four valves had dysfunction and calcification during pregnancy and two before pregnancy. The pregnancies resulted in three abortions, seven normal deliveries and four caesarean section with obstetric indication. Fetal distress was not observed during or after delivery. The physiopathology of valve dysfunction during pregnancy was discussed and it was concluded that the biologic porcine prosthetic valve allows hemodynamic stabilization. If dysfunction appears it may be clinically controlled without need of anticoagulation, risk of calcification nor dysfunction during pregnancy. The biologic valves are best indicated for women who wish to become pregnant after valve substitution.